Neonatal Virtual Care Feedback form

Partner Location

My role during the neonatal virtual care consult

Physician Lead-patient site

RN-patient care

Ancillary support-patient site

Children's NNP

Children's MD

My Name

Date of Consult

Time of Consult

1. Indication for Neonatal Virtual Consult

Prematurity

Respiratory distress

Perinatal depression

Congenital anomalies

Abnormal exam

Seizures

Suspected Sepsis

Cardiac

Hematologic

Other

If other:

2. Consulting clinicians worked collaboratively with each other and with our care team:

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

3. This Neonatal Virtual Care consult improved patient safety and patient quality of care:

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

4. The Neonatal Virtual Care Service technology was easy to use with clear audio/visual connection:

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Was phone consultation back-up used?

Used due to technology issues

Used due to training issues

5. Request for Transport

Request was made at the initiation of Neonatal Virtual Care consult

Request was made during the Neonatal Virtual Care consult

Request was made at the end of the Neonatal Virtual Consult

No transport requested

6. Patient Disposition

Remained at birth facility

Transferred to Children's Minnesota NICU - Minneapolis

Transferred to Children's Minnesota NICU - St. Paul

Transferred to a different NICU

Expired

7. If you kept the neonatal patient at your hospital, was the virtual care consultation with Children's a contributing factor?

Yes

No

Virtual Care was helpful but did not affect our decision whether to keep or transfer the baby

8. I would use the Neonatal Virtual Care again and would recommend it to my colleagues

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

9. The benefit I most appreciated about Neonatal Virtual Care was:

Assisted with pre-delivery set up

Assistance with medication dosing

Collaborative team care

Improved resuscitation of patient

Increased confidence in care delivery

Other

If other

Comments and/or recommendations about how we might improve our service to your team:

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